Provider Demographics
NPI:1437376431
Name:KOEUT, SODETH (BS)
Entity Type:Individual
Prefix:MR
First Name:SODETH
Middle Name:
Last Name:KOEUT
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4840 WIGHTMAN ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-2949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5296 UNIVERSITY AVE STE F1
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-2269
Practice Address - Country:US
Practice Address - Phone:619-229-6725
Practice Address - Fax:619-229-1819
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2008-09-05
Deactivation Date:2008-03-18
Deactivation Code:
Reactivation Date:2008-09-05
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator